If it’s on the pitch, is it interfering with...
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If it’s on the pitch, is it interfering with play? Craig Williams
Transcript of If it’s on the pitch, is it interfering with...
Ifit’sonthepitch,isitinterferingwithplay?
CraigWilliams
Therearelotsofbugsinulcers!
• Labreport
Ifit’sonthepitch,isitinterferingwithplay?
Thedifferencebetweenmicrobiologyandcardiology
Doubtisnotapleasantcondition,butcertaintyisabsurd
Voltaire
DiabeticfootulcersareaproblemMorethan60,000peoplewithdiabetesinEnglandarethoughttohavefootulcersatanygiventime.In2014-15theannualcostofdiabeticfootdiseasetotheNHSinEnglandwasestimatedat£1billion,inadditiontothepersonal/socialcostsofreducedmobilityandsicknessabsence.Onlyaroundhalfofpeoplewithdiabeteswhohavehadadiabeticfootulcersurvivefor5years.Treatmentfordiabeticfootdiseasemayinvolveamputation.Around7,000peopleeachyear. NationalDiabetesFootCareAudit-
2014-2016
Table 8: Factors associated with being alive and ulcer-free at 12 and 24 weeks, England and Wales, 2014-2016
Factors associated with healing
Outcome at ___ weeks
12 24
Associated with better healing
Patient is female p p
Patient is from a less deprived area of the country tu p
Patient has Black or Asian ethnicity p tu
Patient has Type 1 diabetes p tu
Patient has had diabetes for less than 5 years p p
Patient has had diabetes at least 5 and less than 10 years p tu
Patient self-referred to the specialist foot care service p tu
Associated with worse healing
Patient has mixed or ‘other’ ethnicity tu q
Patient currently smokes q tu
Patient presented with Charcot foot disease q q
…with Site/Ischaemia/Neuropathy/Area/Depth q q
…with Bacterial infection q tu
Patient waited more than 2 months for expert assessment q q
Patient has not had all 8 NICE recommended processes q q
Key: Strength of models (c-statistic) = poor. See Glossary (Statistical terms) in the main report for explanation of terms.
▲ = Associated with better healing; ▼ = associated with worse healing;◄► = no association found. Tested at the 0.05 level.
Table 10: Ulcer factors associated with ulcer healing at 12 and 24 weeks, England and Wales, 2014-2016 12 weeks 24 weeks Strength of model (c-statistic)1 Poor 0.697 Poor 0.672
Ulcer characteristicOdds ratios1
12 weeks 24 weeks SINBAD element: Site (on hindfoot) q 0.810 q 0.702 SINBAD element: Ischaemia q 0.494 q 0.482 SINBAD element: Neuropathy q 0.637 q 0.756 SINBAD element: Bacterial infection q 0.792 tu SINBAD element: Area (≥1cm2) q 0.504 q 0.594 SINBAD element: Depth (to tendon or bone) q 0.670 q 0.684 Charcot foot disease = present2 q 0.722 q 0.620 Charcot foot disease = possible2 p 1.600 tu Charcot foot disease = unknown2 p 1.248 tu Time to expert assessment = self-referred3 p 1.191 tu Time to expert assessment = >2 months3 q 0.557 q 0.595
Notes: 1. See Glossary (Statistical terms) in the main report for explanation of terms. 2. Vs. Charcot foot disease = not present 3. Vs. Time to expert assessment = ≤2 days.
Key: Strength of models (c-statistic) = poor. See Glossary (Statistical terms) in the main report for explanation of terms. ▲ = Associated with better healing; ▼ = associated with worse healing;◄► = no association found. Tested at the 0.05 level.
Rememberthechangebetween12and24weeks
There are lots of bugs everywhere!
Especiallyontheskin• The skin, our largest organ is completely covered with microbes,
with an estimate of about 1 billion microbial cells per cm2 of skin covering its surface and extending down into the appendages and glands
• Variability between individuals and variability between different body sites is common
• the dominant genera of skin bacteria are relatively stable and include Staphylococcus, Propionibacterium, and Corynebacterium,
• Streptococcus and Pseudomonas are isolated less frequently but account for most variability
KongJinvestDermatol2012Mar;132(3Pt2):933-9
Arediabeticsdifferent?
Thediabeticmicrobiota
phylumActinobacteria,(Corynebacterium),ismoreprevalentindiabeticfootskinNofollowupsonoextrapolationtopossibleDFUprognosticmicrobialsignatureswasattainablewiththisstudy.
RedelJInfDis2013Apr;207(7):1105-14
Isthereabadmicrobiome
Smith K. BMC Microbiol 2016 Mar 22;16:54
Eachulcerisanexperimentinbacteriology
Don’tforgetthefungi
KalanMbio2016
Sofar
• Complexmixtureofbacteriaandfungi• Nosmokinggunsofar
HowdoorganismsgrowinulcersBiofilms are present in most, if not all, chronic non-healing wounds 78% of chronic wounds contain a biofilm. Micro-organisms in biofilms are not only located at the wound surface but may also be present in deeper tissues
Malone J Wound Care 2017;26:20-5 Schaber Infect Immun2007;75:3715-21
Howisthebiofilmgrowing?
EurJOralSci.2007,115:459–467.JClinMicro2008,8:2717-22
Streptococci Actinomycesnaeslundii
FunctionallyEquivalentPathogroup:consortiaofgenotypicallydistinctbacteriathatsymbioticallyproduceapathogeniccommunity.
Whatdoescompetitionmean?
• Mixturesinbiofilmsbehavedifferentlytoplanktonicmixtures
• StaphaureusandPseudomonas
• Biofilmsoveralldeveloptoreduceimmunogenicity
• Complexinter-kingdomandinter-speciesinteractionsoccurinbiofilm
Bacterial interaction: Staph and Pseudomonas
Armbruster et al. mBio 2016; doi:10.1128/mBio.00538-16
ProteinAfromSaureusprotectsPsaeruginosafromneutrophilphagocytosis
Bacterial interaction: Staph and Pseudomonas
Limoli et al. mBio 2017; doi:10.1128/mBio.00186-17
Ps aeruginosa isolates from coinfected CF patients are less competitive with S. aureus.
Inter-kingdominteractions:CandidaandStaph
Kean.FrontMicrobiol.2017Feb23;8:258
Inter-kingdominteractions:CandidaandStaph
Kean.FrontMicrobiol.2017Feb23;8:258
Bacterialinteractionsinbiofilms:Mousemodel
P.aeruginosa
S.aureus E.faecalis,F.magna,andhostcellDNA
DaltonPLoSOne2011;6(11):
Mixedinfectionsdelayhealing
Doesthe“immunogenicity”ofthemixedbiofilmchangeovertimeThemiddleperiod(12weeks)seemstobeimportant
DaltonPLoSOne2011;6(11):
Rememberthechangebetween12and24weeks
Sofar
• Thebugsgrowasbiofilms,probablyindiscreteclumpsof“competing”bacteriain“unhappy”biofilms
• Bacterialspeciescan• interacttomodifyhostresponse• Interactwitheachothertoallowotherspeciestothrive
• Interactwithfungitoincreasepathogenicity
Thisisallverycomplicated
The hydrogel-cellulose matrix (3D) model
C the cellulose matrix containing the microorganisms B 50% serum gel Allows the form of a 3D biofilm
structure.
A B
2Dv3Dmodel
C a S a P a10 0
10 1
10 2
10 3
10 4
10 5
10 6
10 7
10 8
O rg an ism
CFU
/mL
U n trea ted
P V P - I
C HX
# # # #
****
***
***
C a S a P a10 0
10 1
10 2
10 3
10 4
10 5
10 6
10 7
10 8
10 9
10 10
O rg an ism
CFU
/mL
U n trea ted
P V P - I
C HX
#* #
***
******
***
IndividualorganismsgrownonThermanoxcoverslips(2D)
IndividualorganismsgrowninCellulosematrix(3D)
CHXPVICONT
TownsendBiofouling2016Nov;32(10):1259-1270
2Dv3Dmodelwithantiseptics
TownsendBiofouling2016Nov;32(10):1259-1270
Viabilityin2Dand3DsystemsU n tre a te d
T o ta l L ive0
2 0
4 0
6 0
8 0
1 0 0
C a
S a
P a
Pe
rce
nta
ge
(%
)
1 .2 3 x 1 0 7 1 .5 3 x 1 0 6
P V P -I
T o ta l L ive0
2 0
4 0
6 0
8 0
1 0 0
C a
S a
P a
Pe
rce
nta
ge
(%
)
9 .2 1 x 1 0 5 3 .4 5 x 1 0 4
C H X
T o ta l L ive0
2 0
4 0
6 0
8 0
1 0 0
C a
S a
P a
Pe
rce
nta
ge
(%
)
3 .0 2 x 1 0 7 1 .2 5 x 1 0 6
UNTREATED
UNTREATED
PVI
PVI CHX
CHX
3Dmodelwithantimicrobials
TownsendAntimicrobAgentsChemother.2017Aug24;61(9).
Flucloxacillin
Ciprofloxacin
Fluconazole
TownsendAntimicrobAgentsChemother.2017Aug24;61(9).
https://woundsinternational.wordpress.com/tag/biofilm/
Muchofthefocusonpathogenesishasbeenonalteredneutrophilfunctionsuggestingthatinefficientchemotaxis,pooractivation,orfailuretoresolveinflammationpreventanappropriateresponsetomicrofloraandpromotetissuedestruction
MuchofthefocusonpathogenesisofLAPhasbeenonalteredneutrophilfunctionsuggestingthatinefficientchemotaxis,pooractivation,orfailuretoresolveinflammationpreventanappropriateresponsetomicrofloraandpromotetissuedestruction
Whataboutthehost
Biofilmstatenotbiofilmsource
• Biofilmsource(i.e.derivedfromahealthyordiseasedsite)doesnotinfluencepatternofimmuneresponse,
• Biofilmstate(i.e.homeostaticvs.disequilibrium)doesinfluencethepatternofimmuneresponse
VelskoOralMicrobiol2017Jun12;9(1):
Samebiofilmdifferentresponse
Intactbiofilmsarelessrecognizableandmoredifficulttophagocytosebymacrophagesduetotheextracellularmatrixthatcoatsand‘hides’thebacteriainthebiofilm.Differencesintheresponsestointactversusdispersedbiofilmsinboththemagnitudeandthepatternofthecytokineresponse,MacrophagesareskewedtoanM2phenotypewhenexposedtoS.aureusinabiofilm,renderingthemlessinflammatoryandlesscapableofclearingthebiofilmthanM1-typemacrophages
ThurlowJImmunol2011,186;11:6585-96.
Doesthehostselectthebacteria
E.coli(×),S.aureus(◆)(◊)A.baumannii(─),P.aeruginosa(●),(ο),(▪)
GonzalezmSphere2016Apr27;1(2).
Conclusion• Dynamicsnotconstituentsofbiofilmmaydetermineoutcome
• Windowofopportunityforbacteriatohaveanyinfluenceonulcerswhichisoverby24weeks.
• Blackboxbacteriologyvstampcollecting
• Antibioticstreatinfectionbutwilnothealwoundsandmayhaveunexpectedeffectsonbiofilm.
SoshouldwetreatthePseudomonas?
• Labreport
Thanks
GordonRamageRanjithRanjendranLeighannSherry
KarenSmithEleanorTownsendRyanKean
AndyCollier
